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II. ХИРУРГИЯ
IS RESECTION OF THE ANTRUM USEFUL IN CASE OF LONGITUDINAL RESECTION OF THE STOMACH?
МРНТИ 76.29.34
Omarov T.I., Zeinalov N.A., Bayramov N.Y.
Azerbaijan Medical University, I Department of Surgical Diseases, Modern Hospital, Bariatric-Metabolic Surgery Department, Baku, Azerbaijan.
Abstract
Objective: Comparative analysis of the resection of the antrum with longitudinal gastrectomy in patients with extreme obesity. Material and methods: The work included the results of 118 sleeve gastrektomy operations performed in 2012-2018 in patients with obesity [mean age - 30 years; the average body weight index is 54.2 kg / m2]. The first group included 61 (51.7%) patients who underwent standard laparoscopic longitudinal gastrectomy (sleeve gastrectomy), and the second group consisted of 57 (48.3%) patients who underwent resection of the antrum at the time of standard longitudinal gastrectomy for the formation of an even smaller size of the stomach. In both groups, from the point of technical modification, after 1, 3, 6 and 12 months postoperative difficulties were comparatively analyzed: BMI, diabetes, hypertension, sleep, apnea syndrome were examined in patients before and after surgery, special methods of examination were carried out, the dynamics of fatty liver disease was traced. Results: In the first 6 months 61 (51.7%) patients who underwent surgery, dropped an average of 39.5 + 11.5 kg of body weight, which amounted to 65-50% of excess weight and 28-40% of the total body weight of the patient. In 57 (48.3%) patients who had a smaller stomach after antrumectomy, this difference was 44± 13 kg. In group I with the standard laparoscopic longitudinal resection of the stomach (sleeve gastrectomy), in the first 12 months after surgery, weight loss amounted to 62±7.5 kg. In group II whith the sleeve gastrectomy + antrumresection, wight loss amounted to 73 ± 8 kg The results of calculating the percentage of weight loss ratios by the end of 12 months showed the effectiveness of the method and amounted to 43.4%. The results obtained in all these patients are based on observations carried out for 36 months. The dynamics of observation for 12 months showed the disappearance of signs of fatty degeneration in all patients. In 38 of 43 patients suffering from type II diabetes, after one month, the level of glucose in the blood returned to normal amounts without taking antidiabetic drugs, and 5 patients reduced the dose of the drug. In addition to the above, in both groups, patients who underwent a sleeve gastrectomy did not need vitamin-mineral support after the first three months. Considering the results of the conducted research, it can be concluded that with a modified stomach reduction operation (sleeve gastrectomy) in patients with extreme obesity, weight loss and recovery from concomitant diseases, in comparison with the standard group, occurs more efficiently and quickly.
Асказанды бойлык резекциялау отасы кезшде антральды белтн резекциялау пайдалы ма?
Омаров Т.И., Зейналов Н.А., Байрамов Н.И.
Эзiрбайжан медицина университету I Хирургиялык аурулар бeлiмшеri,
Модерн Госпиталь, Бариатриялык-Метаболиялык хирургия бeлiмшесi, Баку, Эзiрбайжан
Ацдатпа
Максаты: анык KepiHeTiH ceMipyire шалдыккан пациенттердщ бойлык гастроэктомиясымен аскрзанныц антральдык белюн резекциялауыныц салыстырма талдауын журпзу. Материал жане адстер. Бул жумыска ceMipin кеткен пациенттерге 2012-2018жылдарда жасалеан 118 гастроэктомия нэтижелерi фген (орта жас мeлшepi-30жас; дене массасыныц орта есеппен ашниндекс 54,2кг/м2] курады. Бipiншiтопты стандартылапароскопиялык бойлык гастрэктомия (жецдк гастрэктомия), отасынжасаткан 61 (51,7%) пациент курады, ал екШ топты аскрзанныц
ABOUT THE AUTHORS
Tariel Omarov, Ph.D., Assistant Professor, Department of Surgical Diseases, Azerbaijan Medical University. [email protected]
Nuru Bayramov, MD, Professor. Head of the Department of Surgical Diseases
Keywords
Severe obesity, sleeve gastrectomy, 32 Fr, antrumectomy, pyloric sphincter
АВТОРЛАР ТУРАЛЫ
Тариф Омаров, t.f.k., дзiрбайжан медициналыкуниверситет хирургиялык аурулар кафедрасыньщ ассистентi. [email protected]
Нуру Байрамов, м.Ед., хирургиялык аурулар кафедрасыныц мецгеруш^
Туйш сездер
ауыр турде ceMipy, же^к гастрэктомия, 32 Fr, антрумэк-томия, пилориялык сфинктер.
шатын квлeмiн калыптастыру ушШ стандартты бойлык гастроэктомияжасау кез'1нде асказанныц антральды бвлюне отажасалтан 57(48,3%) пациентке. Ею топта да, техникалыкмодификациялау туррысынан, 1,3, 6жэне 12айында от-адан кейЫ мepзiмгe салыстырма талдаужасашн: ИМТ, диабет, артериалдык гипертензия, уйкы, апноэ синдромы, пациeнттepдiн отара дeйi жэне отадан кeйiн зерттелген, тексерудщ арнайы эдicтepi бауырдын майлы ауруларынын динамикасын зерделеу максатында зеттеулер журпзюген. Нэтижелер: б'1р'1нш'1 6 айында 61 (51,7%) операция жасаткан пациенттер орта есеппен ашнда дене массасыныц 39,5 + 11,5 кг курады, ондай жайт 65-50% курады, дене массасыныц артьшнан жэне 28-40% жалпы дене массасынан. Антрумэктомия отасынан кейн асказаны азайып кашн 57(48,3%) пациенттердц айырмашылыты 44± 13 кг курады. 1ш топка асказанныц стандартты лапароскопиялык бойлык резекциялауымен (жещк гастрэктомия) жасаткдн пациенттер кipeдiжэне б'р'нш'! 12 айында отадан кейн салмак тастатан 62±7,5 кг курады. II-шi топта же^к гастрэктомиясымен + антрумрезекциясымен салмак тастатан 73 ± 8 кг курады. 12 айдыц соцында салмак тастатан коэффициента есепайырысу нэтижeлepi э^с^н тиiмдiлiгiн кврсетл, ондай кврсеткш 43,4% курады. Барлык осы пациенттерден алынтан нэтижелер 36 ай iшiндe журпзшген кадаталаула непзделген. 12 айдыц шндеп кадаталау динамикасы барлык пациенттердц май дегенерациясыныц белплер'1 жойылтанын кврсетет. II туршдеп диабете шалдыккан 43 пациентЫц арасынан 38 пациентнде бip айдан кейн канындаты глюкоза децгей диабетке карсы препараттарды тутынбай-ак калыпты децгеШне жет, ал 5 пациент осы препараттардыц мвлшерн твмендет. Баяндалтанныц нeгiзiндe жецдк гастрэктомия жасаткан ею топтаты пациенттерге косымша ретнде б'1рнш'1 уш айдан кeйiн дэpyмeндi-минepалды колдау ретнде ем жасауды кажет ет-пеген. бтюзшген зерттеудц нэтижeлepiн есепке алуымен асказанды азайту бойынша модификациялантан операция кезнде ceмipгeнi анык кврнген пациенттеге леспе ауруларынан салмарын тастау жэне сауытып кету стандарты тап-пен салыстыртанда, тиiмдipey жэне жылдам втуде.
Полезна ли резекция антрального отдела при операции по поводу продольной резекции желудка?
ОБ АВТОРАХ
Тариель Омаров - к.м.н.,ассистент кафедры хирургических болезней Азербайджанского медицинского университета (АБУ). [email protected]
Нуру Байрамов - д.м.н..профессор зав. кафедрой хирургических болезней
Ключевые слова
тяжелое ожирение, рукавная гастрэктомия, 32 Fr, антрумэк-томия, пилорический сфинктер
Омаров Т.И., Зейналов Н.А., Байрамов Н.И.
Азербайджанский Медицинский Университет, Отделение Хирургических болезней I, Модерн Госпиталь, Отделение Бариатрически-Метаболической хирургии, Баку, Азербайджан
Аннотация
Цель: провести сравнительный анализ резекции антрального отдела желудка с продольной гастрэктомией у пациентов с выраженным ожирением. Материал и методы. В работу включены результаты 118 гастроэктомии, выполненных в 2012-2018 гг. у пациентов с ожирением [средний возраст - 30 лет; средний индекс массы тела составил 54,2 кг/ м2]. Первую группу составили 61 (51,7%) пациент, перенесший стандартную лапароскопическую продольную гастрэктомию (рукавная гастрэктомия), а вторую группу составили 57 (48,3%) пациентов, которым была сделана резекция антрального отдела желудка во время стандартной продольной гастрэктомии для формирование меньшего размера желудка. В обеих группах с точки зрения технической модификации, через 1, 3, 6 и 12 месяцев были сравнительно проанализирован послеоперационный период: ИМТ, диабет, артериальная гипертензия, сон, синдром апноэ были исследованы у пациентов до и после операции, специальные методы обследования были проведены с целью изучения динамики жировой болезни печени. Результаты: за первые 6 месяцев 61 (51,7%) пациент, перенесший операцию, сбросил в среднем 39,5 + 11,5 кг массы тела, что составило 65-50% от избыточной массы тела и 28-40% от общей массы тела. У 57 (48,3%) пациентов, у которых после антрумэктомии желудок уменьшился, разница составила 44± 13 кг. В I группе со стандартной лапароскопической продольной резекцией желудка (рукавная гастрэктомия) в первые 12 месяцев после операции потеря веса составила 62±7,5 кг. Во II группе с рукавной гастрэктомией + антрумрезекцией потеря веса составила 73 у 8 кг. Результаты расчета коэффициентов потери веса к концу 12 месяца показали эффективность метода и составили 43,4%. Результаты, полученные у всех этих пациентов, основаны на наблюдениях, проведенных в течение 36 месяцев. Динамика наблюдения в течение 12 месяцев показала исчезновение признаков жировой дегенерации у всех пациентов. У 38 из 43 пациентов, страдающих диабетом II типа, через один месяц уровень глюкозы в крови вернулся к нормальному уровню без приема противодиабетических препаратов, а 5 пациентов снизили дозу этих препарата. В дополнение к вышесказанному, в обеих группах пациентам, перенесшим рукавную гастрэктомию, не требовалась витаминно-минеральная поддержка после первых трех месяцев. Учитывая результаты проведенного исследования, можно сделать вывод, что при модифицированной операции по уменьшению желудка у пациентов с выраженным ожирением потеря веса и выздоровление от сопутствующих заболеваний, по сравнению со стандартной группой, происходит более эффективно и быстро.
Introduction
Currently, the number of people with obesity is increasing. Researchers associate it with inactivity, the adoption of high-calorie foods, hormonal changes and other reasons. In recent decades, re-searchs have shown that the prevalence of obesity in the population has become an epidemy. Accord-
ing to forecasts of the World Health Organization in 2025, 50% of women and 40% of men have the probability of morbid obesity or severe obesity. In the structure of extreme obesity, the main place is occupied by type 2 diabetes, arterial hypertension, and dyslipidemia. Metabolic obesity (MO) and metabolic syndrome (MS), along with a negative ef-
fect on vital quality, is also characterized by high mortality. All of the above prove important medical and social benefits of the problem. Currently, in the treatment of MO and MS, bariatric surgery has acquired priority [1,2]. Obesity, being a chronic, multisystem disease, is the cause of many problems in the human organism. This pathology is one of the progressively growing serious medical problems, especially in developed countries. Type II diabetes, hypertensive disease, impaired venous circulation, hypercoagulapathy, fatty degeneration of non-alcoholic origin, reproductive system defects are the main complications [3.4]. In the initial stage of treatment determines methods of conservative correction. But practice shows that with the development of limiting obesity, the methods of medical correction are not so satisfactory and there is a need for sufficient material consumption and prolonged observation [5]. In this regard, the current focus on bariatric surgery is associated not only with the method of weight loss in extremely obese patients, but is also a treatment of type II diabetes and its associations on the first place. Bariatric surgery is not only a correction of the MO and its associations, it also improves the quality of life and continuance. The treatment of the basic composition of MO and MS with bariatric intervention provides faster social adaptation. Therefore, the widespread "epidemy" on the background of MO makes the question of its correction by new methods more relevant. In this regard, in surgical practice endovid-eosurgical technologies stubbornly developing and widely implementing. In recent decades, laparo-scopic methods have rapidly become established in bariatric surgery, minimally invasive and low-impact interventions have improved the medical and social environment in surgical treatment. Due to this, indications for surgical treatment are expanding. Currently, in order to increase the rationality of treating obesity, various types of bariatric operations are utilized. The relatively recent introduction of surgery in cases of extreme obesity has aroused interest in research of the treatment results in various aspects [6,7,8]. The fundamental concept of the most effective treatment of obesity in bariatric surgery is the reduction of appetite and food digestion by the gastrointestinal system, which achieves by utilizing one or both of the principal pathways: reducing intestinal absorption (malabsorption operations) and reducing the stomach (restrictive operations) or symbiotic operations, including both methods at the same time. In the surgery of obesity the goal is, along with ensuring ideal weight loss, to assist in the treatment of associated diseases [11,12]. In most patients who undergo surgical treatment of obesity, sleeve gastrectomy is preferred among other bariatric methods.
Purpose: Comparative examination of the results of various methods of operations for standard longitudinal gastric resection (sleeve gastrectomy - SG) in patients with extreme obesity.
Material and methods
Research included the results of 118 sleeve gastrectomy operations performed at the Modern Hospital and at the educational and surgical clinic of the Azerbaijan Medical University from 2012 to 2018 in patients with obesity [mean age -30 years; the average body weight index is 54.2 kg / m2]. Surgical indications were established according to the criteria of the IFSO (International Federation for Surgery of the Obesity and Metabolic Disorders) 2006 Bariatric Surgery. Marked body weight before surgery, body mass index (BMI) and associated diseases. Before the operation, all patients underwent gastroscopy to examine the gastrointestinal system and ultrasonography to identify the pathology of the liver and biliary tract. In the preoperative period all patients were consulted by a pulmonologist, a cardiologist, a nutritionist, a psychologist and an endocrinologist; anesthetic risk was also assessed.
Before and after the operation fractional hepa-rin was utilized. Varis stockings and dynamic foot massagers were additionally worn on the patients before operation. Antibiotics of the cephalosporin group were prescribed in single dose before operation and in double dose after. The performed technically modified operations were divided into two groups. Group I included 61 (51.7%) patients who, after standard measures, underwent standard laparoscopic longitudinal gastrectomy (sleeve gastrectomy - SG), were resected with a 36 Fr calibration tube, 4-6 cm more proximal to the pyloric sphincter (this is the initial years of our operations). As a result, a stomach is formed in a volume of 120-140 ml. And group II consisted of 57 (48.3%) patients who underwent standard laparoscopic longitudinal gastrectomy (sleeve gastrectomy - SG) + antrum resection. The resection was performed with a 32 Fr calibration tube, antrum removed 2-3 cm proximal to the pyloric sphincter. As a result, the stomach is formed 8090 ml. In the postoperative period, the patients stayed for 1-3 days. The technique of operations in both groups was carried out according to international standards, but in group II laparoscopic longitudinal gastrectomy (sleeve gastrectomy -SG) was slightly technically modified. According to the world literature, the use of the calibration tube 32-42 Fr does not affect the loss of body weight during the first 6 months, despite these data, we still recommend using 32 Fr because of the long-term favorable results.
Looking through modern literature it can be noted that resection should be performed at a distance of 4-6 cm from the pyloric sphincter. During our operations with the 32 Fr calibration tube, resection performs at a distance of 2 cm from the pyloric sphincter in the antrum area parallel to the body of the stomach and the lesser curvature to the bottom (fundus). As a result of applying these 2 methods, we form a stomach of a smaller volume, and as a result achieve even more serious and prolonged weight loss. At the next stage, methylene blue introduces into the stomach lumen to control the stapler line. During surgery, to control bleeding and minimize the risk of leakage, the staple line is sutured (sometimes with omen-topection). The use of omenopection prevents further torsion of the stomach stump, usually about 1 cm in diameter, and follows the goal of maximum control of the staple line infiltration. For prophylactic control of stapling line infiltration, drainage is placed in all patients. The operation ends with the removal of the resected stomach through a 15 mm trocar. Due the utilization of a modified operative technique, postoperative difficulties were comparatively analyzed; before surgery and 1, 3, 6 and 12 months after surgery, BMI was observed in dynamics, probable hypertension, and special examinations of fatty liver were also taken into account.
Results
Of 118 patients with extreme obesity [mean age - 30 years; the average body mass index is 54.2 kg / m2] included in this research: 93 (78.8%) were women, 25 (21.2%) men. Of them: 43 (36.4%) patients had type II diabetes, or prediabetes; hypertension in 33 (27.9%) patients; 19 (16.1%) patients with sleep apnea; 17 (14.4%) women with hormonal disorders associated with polycystic ovarian disease; in 5 (4.2%) men lack of sexual function; in 14 (11.8%) - degenerative osteoarthritis; in 1 (0.8%) patient with chronic obstructive pulmonary disease; 2 (1.7%) patients had a condition after coronary stenting due to ischemic heart disease, and almost all patients (98%) had grade IV obesity. Surgery in 2 (1.7%) patients were laparotomic, in the remaining 116 (98.3%) cases laparoscopic procedures were performed. The average duration of the operation was 2.5 ± 0.5 hours; patients in the clinic had an average of 2.5 ± 0.5 bed-days. Fatal outcome was not observed. One (0.8%) patient underwent a second operation after 4 days due to insufficiency of the anastomosis. In one (0.8%) patient hypotension was noted on the next day after operation, correction was made by infusion and drug therapy. In 1 (0.8%) case 3 days after surgery, and in 1 (0.8%) case a month later, dysphagia appeared, corrected
by conservative treatment, no mechanical narrowing was detected with endoscopy. After 3 months without treatment, the patient's condition returned to normal. During 6-month follow-up, positive dynamics was observed in all our patients, and by the end of 12 months, with the exception of 1 patient, normal values were obtained. In 1 (0.8%) patient 5 days after the operation an anastomosis failure in the fundus portion of the stomach was found. The patient was urgently hospitalized, and the subhe-patic and left subdiaphragmatic areas were percu-taneously drained on the background of appropriate intensive therapy. The next day, a full closed bariat-ric stand was installed, and after 3 days the patient was sent home under outpatient monitoring. After 5 weeks of dynamic control, the stand was removed, the subsequent period passed without complications.
Two months after surgery, 11 (8.6%) patients had gastroesophageal reflux, and 1 (0.8%) patient had a dumping syndrome. In the postoperative period, in the first 90 days, appropriate treatment was carried out with proton pump blockers, acid neutralizers and diet. In the first 6 months, patients of group I after standard laparoscopic longitudinal gastrectomy (sleeve gastrectomy - SG) lost approximately 39.5 ± 11.5 kg. And in patients of group II with the formation of smaller sizes of the stomach, weight loss averaged 44.5 ± 13kg. However, in patients of group I, after standard laparoscopic longitudinal gastric resection (sleeve gastrectomy - SG) for the next 6 months, compared to the first 6 months, the mass loss index gradually decreased and amounted to 22.5 ± 4.5 kg. And in patients of group II, with the formation of smaller sizes of the stomach and resection of the antrum, this figure, in comparison with the standard group, was 28.5 ± 6.5 kg. After 12 months, in the first group, the weight loss in general was 62 ± 7.5 kg, and in the second group - 73 ± 8 kg. Also, in both groups, patients, who underwent sleeve gastrectomy, did not need vitamin-mineral support after the first 3 months. In the first 3 months blood tests were performed for all patients, and, if necessary, vitamin and mineral treatment was carried out by parenteral route. Given all this, in the second group of patients with the formation of a smaller stomach size, weight loss and regression of concomitant diseases were more effective, compared with group I. By the end of 12 months, the percentage of overweight ratio was 43.4%, which demonstrates the effectiveness of this method.
Conclusions
Considering the results of the conducted research, it can be concluded that with a modified stomach reduction operation (sleeve gastrectomy)
in patients with extreme obesity, weight loss and recovery from concomitant diseases, in comparison with the standard group, occur more effectively and quickly. After a new technical modification of the operation of the sleeve gastrectomy in patients with
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